Clinical inquiries. What is the best approach to the evaluation of hirsutism?

■ Evidence summary Hirsutism is the presence of excess terminal hairs in androgen-dependent areas on a female, and can be measured objectively using a scoring system such as the modified Ferriman-Gallway (mF-G) score. This test is done by adding hair scores (0=none, 4=frankly virile) in 9 different body locations. A total score >8 is considered hirsute. The incidence of hirsutism in the US is about 8%, based on a prospective study of 369 consecutive women of reproductive age seeking pre-employment physicals in the southeastern US using the mF-G criteria. The causes of clinically apparent androgen excess, including acne and hirsutism, were evaluated in 1281 consecutive patients presenting to a university endocrinology clinic. Researchers excluded 408 subjects due to the inability to assess hormone status or ovulatory function. The remaining 873 women were assessed by clinical exam, mF-G score, serum total and free testosterone, DHEAS, and 17-hydroxyEarly work on expectations by physician and patient leads to a better outcome Primary care physicians field questions about nonspecific findings on a day-to-day basis. Hirsutism is a common complaint and physical finding in women. Most diagnoses related to hirsutism are not lifethreatening and have a relatively straightforward workup. There is the occasional patient with a zebratype diagnosis that demands more detailed evaluation. As with most physical findings that have a large subjective component, I find that early management of expectations both on the part of the physician and patient leads to a better outcome whether or not a million-dollar workup shows any definitive pathology. Tim Huber, MD Naval Hospital, Camp Pendleton, Calif The evaluation of hirsutism should begin with a history and physical examination to identify signs and symptoms suggestive of diseases such as polycystic ovarian syndrome (PCOS), hypothyroidism, hyperprolactinemia, hyperandrogenic insulin-resistant acanthosis nigricans (HAIR-AN) syndrome, androgenic tumors, Cushing’s syndrome, or congenital adrenal hyperplasia (CAH). Findings suggestive of these diseases include rapid or early-onset hirsutism, menstrual irregularities, hypertension, severe hirsutism, virilization, or pelvic masses (strength of recommendation [SOR]: B, based on a cohort study in a referral population) (TABLE). Hirsutism with unremarkable history and physical exam findings should be evaluated with a serum total testosterone and dehydroepiandrosterone sulfate (DHEAS) level (SOR: B, based on a cohort study in a referral population). Diana Renee Curran, MD Hendersonville Family Practice Residency, Hendersonville, NC